Primary care physicians are feeling under siege, overworked, and underpaid.32–34
So it is important to provide solutions that are realistic and do not create a new layer of problems. First, financial issues must be addressed head-on, and physicians must be given easy access to resources and tools that they can implement easily in their practice. The UK had the advantage of setting new expectations for primary care physicians at the same time it increased resources to finance health care—through a tax increase enacted specifically to improve access in the National Health Service. In the U.S., it may be necessary to achieve offsetting savings, either in specialty care or in reduced use of hospital and emergency room care to finance improved primary care.
One way to begin would be to ensure that all Americans—whether insured by public programs or private insurance, or uninsured—have a “medical home.” Indeed, patient-centered care ought to begin in the medical home. Adoption of a Danish-style medical home would have many advantages, including improved continuity of care and a clear set of rights and responsibilities for both physicians and patients.
To support the development of medical homes within primary care practices, there would need to be new incentives for primary care physicians. A new system of payment for primary care could include both a medical home monthly fee to encourage better physician-patient communication and coordination of care, combined with the current fee-for-service payment system. The medical home fee component would need to be sufficient to cover the cost of nonreimbursable services such as information technology and other practice systems to ensure patient-centered care, such as patient surveys and patient reminder systems. A model for this could be the blended per-patient fee and fee-for-service system in use in Denmark.29
In the U.S., Newhouse has advocated a blended payment system both as a way of adjusting for the greater health care needs of sicker enrollees and as a way of balancing incentives for overuse and underuse.35
Medicare is currently considering pay for performance for physician services and could be a leader by paying a monthly panel fee as well as rewards for performance on patient-reported experiences with care. Demonstrations to test the concept would be an important first step.
Adding the UK's GP incentive payments for reaching quality targets to this payment system would be an interesting innovation. Paying for performance would focus primary care practices on the importance of measuring and improving quality of care, including conducting patient surveys of patient experiences with care. In the UK system, major “points” are awarded simply for conducting such surveys, informing a supervising physician if there is one (for example, head of a primary care trust), and indicating that they have taken steps to address the concerns. For example, if patients complain that it takes too long to get an appointment, physicians could indicate that they have instituted a system of same-day appointments. Experience with this new reward and reporting system should be followed closely.
In the U.S., patient-centered care practices could be paid a fixed monthly fee for a package of services such as e-mail visits, reminders, access to electronic medical records, and demonstrating easy access to care when needed by the patient. These payments would offset the additional personnel, physician time, information technology, and office system costs that would be required to deliver these services.
Demonstrations would be necessary to test the concept, and a business case could be developed with appropriate costing of the enhanced services. Research would also be needed to document the impact of this patient-centered model of primary care—its impact on quality of ambulatory care, offsetting savings from reduced specialty care, emergency room use, and hospital utilization and, importantly, patient satisfaction and clinical outcomes. Obviously, unless it is demonstrated that there are offsetting savings, this model will not be adopted widely.
There are potentially other primary care payment models that could stimulate better experiences for patients and more satisfied physicians. For example, Allan Goroll, a primary care physician at Massachusetts General Hospital, and his colleagues have been considering the possibility of substituting a monthly retainer payment for all fee-for-service compensation. Such a proposal would need an evaluation similar to the blended payment proposal (A. Gorroll, personal communication, 2004). It differs from boutique medicine in that the retainer replaces fee-for-service compensation, would apply to all patients (not a 2-tiered service), is likely to be considerably lower than “boutique” fees, and could be covered by insurance.36
There is also an important role for organizations in providing training and technical assistance to primary care practices on methods of improving quality of care. Tools—whether shared decision-making videos or information technology systems that give patients access to their electronic medical records—and information on their effectiveness should be developed with public or private support.37
Generation of comparative databases across practices over time would help identify best practices and provide benchmarks against which practices could assess their progress. Care provided in the outpatient, hospital, and nursing home settings also needs to be redesigned. Models of team work are needed that can be efficiently implemented in these various settings and that are easily adaptable to the specific features and flow of patient care. Physicians and other health care professionals will need to be trained to work in such teams whose central member is the patient. Ultimately, patient-centeredness should not only be considered as a priority, but as a precondition of our health care system.
It will undoubtedly take a sustained effort to transform American health care to achieve this vision. It requires champions—primary care leaders and leaders among employers, insurers, and politicians. But with appropriate leadership and policy changes, especially with regard to payment for primary care in private and public insurance plans, all Americans could receive primary care that is truly patient-centered.